HELPFUL HUDDLE Daily "circle ups" are where staff members are welcome to bring any safety-related topic to the table.

The caregivers at The Valley Hospital's Luckow Pavilion in Paramus, N.J., literally signed on the dotted line to earn this year's OR Excellence Award for Patient Safety. Each member of the Valley Hospital system's clinical team is required to ink a Zero Harm Agreement, which states they're dedicated to do whatever it takes to protect those in their care and that one patient harmed is one too many.

The 6-OR freestanding surgery center is under the umbrella of The Valley Hospital, but sits about 4 miles away. "That means it's all hands on deck during a crisis," says Cristina Smith, BSN, RN, CPAN, the center's manager of same day services. "Any staff member who's here needs to know how to help when an emergency — any emergency — arises." Here's how she makes sure they're ready when pulses quicken and seconds count.

• Realistic drills. The center uses incredibly realistic emergency response drills involving the health system's simulation manikins to help prepare staff members for the unexpected, whatever it might be. "The drills create mindfulness of how to recognize emergencies and what to do when they occur," she explains.

During the simulations, staff members know something will go wrong, but they don't know what the emergency will be. That element of surprise keeps them honest, hones their on-the-spot critical thinking skills and lets managers assess how they'd respond to an actual emergency.

TEAM EFFORT
Where Everyone's Opinion Matters

GROUP EFFORT Huddles are held throughout the day at HonorHealth-Thompson Peak Medical Center to discuss safety-related concerns.

At HonorHealth-Thompson Peak Medical Center in Scottsdale, Ariz., administrators are open to listening to any and all ideas, suggestions and concerns voiced by various staff members who rotate through monthly patient care council meetings. Transparency, which is a core principle at HonorHealth, is observed daily in the surgical department. Leadership values every staff member's opinion and tries to provide a forum for everyone to voice their opinions about how patient safety efforts can be improved. The hospital created an Act Team comprised of 2 OR techs and a surgical nurse who implement small-scale process improvement ideas submitted by the frontline staff that could make a big difference in protecting patients. Members of the surgical department are also welcome to attend the hospital's monthly meetings of the Quality Council. Staff members are encouraged to write down their concerns on the meeting's agenda, which is always displayed in the staff lounge. The council's co-chairs address each item on the written agenda and ask every staff member who's present if they have any safety-related concerns to discuss.

The clinical team recently ran through a drill for malignant hyperthermia, "a rare event, and one we'll hopefully never see, but it's the rarity that makes it so important to prepare for," says Ms. Smith. The MH drill convinced the team that seemingly small changes would improve their response protocols. They attached IV poles to MH carts (and code carts) so fluids could be more readily prepared. They also moved some of the equipment needed to mix the dantrolene into the same drawer to make the reconstituting process more seamless. Importantly, the staff learned to look for the red flags of MH. "Treating the condition when the early signs are noticed turns a life-threatening emergency into a manageable crisis," says Ms. Smith. "The outcome is much more dire if you recognize MH after the body's core temperature begins to rise."

SAFE START The surgical team uses the World Health Organization surgical safety checklist during pre-op time outs 100% of the time.

Her team also learned that it's not enough to pull the MH cart to the patient's bedside. Your staff might review the contents of the cart each month to ensure items are stocked and up to date, but they might not remember where supplies are located during the rush of an emergency response unless they practice grabbing them during realistic drills. The drill also proved that as many staff members as possible need to meet at the patient's bedside to grab the MH cart, run for ice to cool the patient and begin reconstituting the dantrolene.

• A just culture. The drills Ms. Smith runs are non-punitive; they're used as educational opportunities to point out what went well and what could have gone better. When adverse events actually do occur, an algorithm is used to determine the root cause and what can be done to prevent the event from occurring again. All team members are encouraged to alert clinical managers to errors that occur — or nearly occur — without fear of punishment. Unless the mistake is egregious, Ms. Smith and her leadership team focus on ways to fix the system that causes a mishap instead of looking for someone to blame.
• Daily discussions. Clinical teams from the pre-op area, the ORs and the PACU gather each morning for a "circle up," where they discuss safety-related concerns they've seen or heard about, and brainstorm ways to better protect patients. They also preview the day's cases and share with the team the information they need to safely care for patients.
• Empowerment. The Valley Hospital made the decision to give nurses, techs, surgeons and anesthesia providers the opportunity to complete a TeamSTEPPS course. The course uses evidence-based teamwork tools to empower everyone in the health system, no matter their position, to speak up when something seems amiss that could result in patient harm, and gives them the autonomy to stop the action if they see an unsafe or potentially unsafe situation. Surgical teams, including surgeons and anesthesia providers who typically work together, gathered in groups and discussed how they would react to several case scenarios involving patient safety issues. "The discussions were team-building exercises, but more importantly they increased the comfort level of everyone involved to speak up around their colleagues," says Ms. Smith.

SAFETY NOTES
Frontline Feedback Drives Change

BOARD CERTIFIED Staff at Andrews Institute Ambulatory Surgery Center welcome staff to write down safety-related concerns on clipboards hung throughout the facility.

Leadership at Andrews Institute Ambulatory Surgery Center in Gulf Breeze, Fla., emphasizes patient safety during daily department huddles, where every team member has a voice. Clip-boards are displayed in each huddle area for any staff member to jot down safety-related concerns, which surgical managers review daily. The simple reporting tool lets the center's leadership solve simple issues quickly and launch quality improvement projects to tackle concerns that demand a more layered response. Employee survey feedback indicates that the facility's safety culture has improved by 11% over the past 2 years and that communication has improved within and between surgical departments. The center's leaders also track and monitor the efforts of past and ongoing QI studies — such as compliance with timeout protocols before operating or placing a regional block — to make sure staff remain focused on the patient safety efforts they helped launch.

Team full of leaders
One of the biggest lessons Ms. Smith has learned while keeping her staff focused on patient safety is the importance of effective leadership during emergencies. She says anesthesiologists or surgeons are expected to lead when the stakes are raised, but she's noticed that nurses and techs are beginning to speak up with ideas and instructions to enhance the center's response protocols and are becoming situational leaders in emergency situations. "That speaks to the importance the facility has placed on patient safety, that it's engrained in our culture and everyone feels comfortable taking ownership in the process," she says.OSM

VIDEO REPLAY
Make MH Drills Count

COOL CUSTOMERS The staff at North Country Hospital is expert in malignant hyperthermia response.

A focus on patient safety is part of the culture at North Country Hospital in Newport, Vt. The surgical services department continuously looks for ways to better protect patients through education initiatives, tabletop discussions and emergency response simulations. They recently performed a malignant hyperthermia education session, which included an AORN video tutorial, a scavenger hunt through the MH cart, a practice session for mixing dantrolene, a review of the duties involved in an MH crisis and the creation of "task" cards for quick reference during an emergency response. The hospital's leadership video recorded the drill and then critiqued it as a group with the staff involved to come up with constructive ways to make the team's performance even better.